Thursday, December 28, 2017

When Daniel Poston, a second-year medical student in Manhattan, opened the App Store on his iPhone a couple of weeks ago, he was astonished to see an app for a new heart study prominently featured.

People often learn about new research studies through in-person conversations with their doctors. But not only did this study, run by Stanford University, use a smartphone to recruit consumers, it was financed by Apple. And it involved using an app on the Apple Watch to try to identify irregular heart rhythms.

Intrigued, Mr. Poston, who already owned an Apple Watch, registered for the heart study right away. Then he took to Twitter to encourage others to do likewise — suggesting that it was part of a breakthrough in health care.

"It's not inconceivable, by the time I graduate from medical school," Mr. Poston said, "that the entire practice of medicine can be revolutionized by technology."

In the last months of Steve Jobs's life, the Apple co-founder fought cancer while managing diabetes.

Because he hated pricking his finger to draw blood, Mr. Jobs authorized an Apple research team to develop a noninvasive glucose reader with technology that could potentially be incorporated into a wristwatch, according to people familiar with the events, who asked not to be identified because they were not authorized to speak on behalf of the company.

It was one of many medical applications that Apple considered for the Apple Watch, which debuted in 2015. Yet because many of the health features proved unreliable or required too many compromises in the watch's size or battery life, Apple ended up positioning the device for activity tracking and notifications instead.

Now, the Apple Watch is finding a medical purpose after all.

In September, Apple announced that the Apple Watch would no longer need to be tethered to a smartphone and would become more of a stand-alone device. Since then, a wave of device manufacturers have tapped into the watch's new features like cellular connectivity to develop medical accessories — such as an electrocardiogram for monitoring heart activity — so people can manage chronic conditions straight from their wrist.

Saturday, December 9, 2017

For decades, experts have warned that older Americans are taking too many unnecessary drugs, often prescribed by multiple doctors, for dubious or unknown reasons. Researchers estimate that 25 percent of people ages 65 to 69 take at least five prescription drugs to treat chronic conditions, a figure that jumps to nearly 46 percent for those between 70 and 79. Doctors say it is not uncommon to encounter patients taking more than 20 drugs to treat acid reflux, heart disease, depression or insomnia or other disorders.

Unlike the overuse of opioid painkillers, the polypharmacy problem has attracted little attention, even though its hazards are well documented. But some doctors are working to reverse the trend.

At least 15 percent of seniors seeking care annually from doctors or hospitals have suffered a medication problem; in half of these cases, the problem is believed to be potentially preventable. Studies have linked polypharmacy to unnecessary death.Older patients, who have greater difficulty metabolizing medicines, are more likely to suffer dizziness, confusion and falls. And the side effects of drugs are frequently misinterpreted as a new problem, triggering more prescriptions, a process known as a prescribing cascade.

The glide path to overuse can be gradual: A patient taking a drug to lower blood pressure develops swollen ankles, so a doctor prescribes a diuretic. The diuretic causes a potassium deficiency, resulting in a medicine to treat low potassium. But that triggers nausea, which is treated with another drug, which causes confusion, which in turn is treated with more medication.

For many patients, problems arise when they are discharged from the hospital on a host of new medications, layered on top of old ones.

Monday, December 4, 2017

Having recently endured more than a month of post-concussion fatigue, I can't imagine how people with so-called chronic fatigue syndrome navigate through life with disabling fatigue that seemingly knows no end. Especially those who are erroneously told things like "It's all in your head," "Maybe you should see a psychiatrist," or "You'd have a lot more energy if only you'd get more exercise."

After years of treating the syndrome as a psychological disorder, leading health organizations now recognize that it is a serious, long-term illness possibly caused by a disruption in how the immune system responds to infection or stress. It shares many characteristics with autoimmune diseases like rheumatoid arthritis but without apparent signs of tissue damage.

Accordingly, doctors now typically refer to it as myalgic encephalomyelitis, meaning brain and spinal cord inflammation with muscle pain, and in scientific papers it is often written as ME/CFS. At the same time, a major shift is underway as far as how the medical profession is being advised to approach treatment.

The longstanding advice to "exercise your way out of it" is now recognized as not only ineffective but counterproductive. It usually only makes matters worse, as even the mildest activity, like brushing your teeth, can lead to a debilitating fatigue, the core symptom of the disease. Both the Centers for Disease Control and Prevention in the United States and the National Institute for Health and Care Excellence in Britain are formulating revised guidelines for managing an ailment characterized by six or more months — and sometimes years — of incapacitating fatigue, joint pain and cognitive problems.

It's the Monday morning following the opening weekend of the movie Blade Runner 2049, and Eric C. Leuthardt is standing in the center of a floodlit operating room clad in scrubs and a mask, hunched over an unconscious patient.

"I thought he was human, but I wasn't sure," Leuthardt says to the surgical resident standing next to him, as he draws a line on the area of the patient's shaved scalp where he intends to make his initial incisions for brain surgery. "Did you think he was a replicant?"

"I definitely thought he was a replicant," the resident responds, using the movie's term for the eerily realistic-looking bioengineered androids.

"What I think is so interesting is that the future is always flying cars," Leuthardt says, handing the resident his Sharpie and picking up a scalpel. "They captured the dystopian component: they talk about biology, the replicants. But they missed big chunks of the future. Where were the neural prosthetics?"

It's a topic that Leuthardt, a 44-year-old scientist and brain surgeon, has spent a lot of time imagining. In addition to his duties as a neurosurgeon at Washington University in St. Louis, he has published two novels and written an award-winning play aimed at "preparing society for the changes ahead." In his first novel, a techno-thriller called RedDevil 4, 90 percent of human beings have elected to get computer hardware implanted directly into their brains. This allows a seamless connection between people and computers, and a wide array of sensory experiences without leaving home. Leuthardt believes that in the next several decades such implants will be like plastic surgery or tattoos, undertaken with hardly a second thought.

Thursday, November 23, 2017

Nurse Laura LaCroix was meeting with one of her many homeless patients in a downtown Dunkin' Donuts when he mentioned that a buddy was lying in agony in the nearby woods.

"You should check on him," said Pappy, as the older man is known. "But don't worry, I put him on a tarp, so if he dies, you can just roll him into a hole."

LaCroix called her boss, Brett Feldman, a physician assistant who heads the "street medicine" program at Lehigh Valley Health Network. He rushed out of a meeting, and together the two hiked into the woods. They found Jeff Gibson in a fetal position, vomiting green bile and crying out in pain from being punched in the stomach by another man days earlier.

Feldman told him he had to go to the hospital.

"Maybe tomorrow," Gibson replied.

"Tomorrow you'll be dead," Feldman responded.

Months later, the 43-year-old Gibson is still in the woods, but this time showing off the six-inch scar — for a perforated intestine and peritonitis — that is evidence of surgical intervention. He greets Feldman warmly. "You're the only person who could have gotten me to the hospital," he says. "You're the only person I trust."

Pappy and Gibson are "rough sleepers," part of a small army of homeless people across the country who cannot or will not stay in shelters and instead live outside. And LaCroix and Feldman are part of a burgeoning effort to locate and take care of them no matter where they are — whether under bridges, in alleyways or on door stoops.

Wednesday, November 22, 2017

John Dalman had been in the waiting room at a Loxahatchee, Fla., dermatology clinic for less than 15 minutes when he turned to his wife and told her they needed to leave. Now.

"It was like a fight or flight impulse," he said.

His face numbed for skin-cancer surgery, Mr. Dalman, 69, sat surrounded by a half-dozen other patients with bandages on their faces, scalps, necks, arms and legs. At a previous visit, a young physician assistant had taken 10 skin biopsies, which showed slow growing, nonlethal cancerous lesions. Expecting to have the lesions simply scraped off at the next visit, he had instead been told he needed surgery on many of them, as well as a full course of radiation lasting many weeks.

The once sleepy field of dermatology is bustling these days, as baby boomers, who spent their youth largely unaware of the sun's risk, hit old age. The number of skin cancer diagnoses in people over 65, along with corresponding biopsies and treatment, is soaring. But some in the specialty, as well as other medical experts, are beginning to question the necessity of aggressive screening and treatment, especially in frail, elderly patients, given that the majority of skin cancers are unlikely to be fatal.

"You can always do things," said Dr. Charles A. Crecelius, a St. Louis geriatrician who has studied care of medically complex seniors. "But just because you can do it, does that mean you should do it?"

Tuesday, November 21, 2017

Every so often, a new study comes along that challenges conventional wisdom in medicine or science. When the conditions are right, these studies can generate a lot of attention in both the popular press and the medical community. In early November, one of these such studies, called the ORBITA study, was published in the Lancet by a group of cardiologists.

The authors had set out to ask and answer a simple question: Does placement of a small wire mesh (called a stent) inside the artery that feeds blood to the heart (the coronary artery) relieve chest pain? One might ask what was novel about this question. The truth is that there was and is nothing novel about the question. The novelty was in the methods the authors used to answer the question: They conducted a prospective randomized controlled clinical trial, or RCT, the gold standard of research. The best RCTs compare the effect of the active intervention to a placebo and the best of the best keep both the subjects and the investigators blind to the intervention. The authors managed to do this for stents and chest pain, something that had never been done before, and in doing so, they had the best chance of preventing the placebo effect from skewing the results.

Sunday, November 19, 2017

Six years ago, at age 49, Julie Gregory paid an online service to sequence her genes, hoping to turn up clues about her poor circulation, blood-sugar swings and general ill health. Instead she learned she had a time bomb hidden in her DNA: two copies of a gene variant, ApoE4, that is strongly linked to Alzheimer's. Most Americans with this genotype go on to develop late-onset dementia.

"Alzheimer's was the furthest thing from my mind," Ms. Gregory told me. "I never thought I was at risk. When I saw my results, I was terrified."

When Ms. Gregory consulted with a neurologist about how to delay the onset of illness, he had four words for her: "Good luck with that." After all, no drug had proven effective in reversing Alzheimer's disease. And preventive measures like diet and exercise, the neurologist told her, would do no good.

Ms. Gregory is not the sort of person who pops into your mind when you think of Alzheimer's — youngish, healthy and sharp-minded. But she represents a type of sufferer we are likely to encounter more and more: those grappling with the looming threat of the disease rather than the disease itself.

Tuesday, November 14, 2017

For the first time, the Food and Drug Administration has approved a digital pill — a medication embedded with a sensor that can tell doctors whether, and when, patients take their medicine.

The approval, announced late on Monday, marks a significant advance in the growing field of digital devices designed to monitor medicine-taking and to address the expensive, longstanding problem that millions of patients do not take drugs as prescribed.

Experts estimate that so-called nonadherence or noncompliance to medication costs about $100 billion a year, much of it because patients get sicker and need additional treatment or hospitalization.

"When patients don't adhere to lifestyle or medications that are prescribed for them, there are really substantive consequences that are bad for the patient and very costly," said Dr. William Shrank, chief medical officer of the health plan division at the University of Pittsburgh Medical Center.

Ameet Sarpatwari, an instructor in medicine at Harvard Medical School, said the digital pill "has the potential to improve public health," especially for patients who want to take their medication but forget.

The nation's leading heart experts on Monday issued new guidelines for high blood pressure that mean tens of millions more Americans will meet the criteria for the condition, and will need to change their lifestyles or take medicines to treat it.

Under the guidelines, formulated by the American Heart Association and the American College of Cardiology, the number of men under age 45 with a diagnosis of high blood pressure will triple, and the prevalence among women under age 45 will double.

"Those numbers are scary," said Dr. Robert M. Carey, professor of medicine at the University of Virginia and co-chair of the committee that wrote the new guidelines.

The number of adults with high blood pressure, or hypertension, will rise to 103 million from 72 million under the previous standard. But the number of people who are new candidates for drug treatment will rise only by an estimated 4.2 million people, he said. To reach the goals others may have to take more drugs or increase the dosages.

Few risk factors are as important to health. High blood pressure is second only to smoking as a preventable cause of heart attacks and strokes, and heart disease remains the leading killer of Americans.

If Americans act on the guidelines and lower their blood pressure by exercising more and eating a healthier diet, or with drug therapy, they could drive an already falling death rate from heart attacks and stroke even lower, experts said.

Tuesday, November 7, 2017

Kasey Smith began gaining weight as a teenager. The numbers on the scale started increasing overnight, and no matter how few calories she consumed, they continued to go up. "It will even out," she thought, crediting the change to puberty and hormones. But it didn't, and her hair and skin began changing as well. "Something was definitely wrong."

Each medical appointment, and there were many, concluded with doctors telling her to go on a diet. Smith (not her real name) remembers telling the endocrinologist about her frustrations with burning off the 900 calories she consumed each day and still gaining weight. "He looked at me and said, 'Maybe you can cut back your McDonald's to twice a week.' I was stunned silent, and I went into the bathroom and broke down. 'He doesn't believe me. He thinks I'm just fucking with him.'"

As Smith's weight went up, her food intake went down. Her mother signed her up for Nutrisystem, and her diet hung on the fridge for everyone in her family to see. Shame and humiliation narrowed her life down to three questions: what to eat, what not to eat, and how to burn more calories. She began to form dangerous habits, sometimes eating little more than lettuce.

Smith ultimately received a diagnosis of polycystic ovary syndrome, a hormonal disorder that can lead to excess male hormones, irregular menstrual cycles, and weight gain. She was prescribed Metformin and quickly began to lose weight, but the damage had been done. The 18-year-old developed anorexia, leaving for college at 130 pounds and coming back four months later and 30 pounds lighter, her hair falling out in clumps.

No one thought anything was wrong.

"I would go to the doctor, and there were no red flags. It was 'You look fantastic!' Not 'This is alarming.'" Smith continued starving herself for another year until she ended up in the hospital, undergoing a colectomy to remove a foot and a half of her intestines, which had twisted as a result of her severe calorie restriction.

One year after the surgery, her worst nightmare returned: She was gaining weight. Celiac disease was the cause this time, but it wasn't diagnosed until after Smith was in the habit of purging the little food she ate every day. She would regularly run in the park and pass out afterward. "I would starve all day, then I'd eat something at night, then I would purge it. In my head, I'm thinking, 'I'm literally not consuming anything. The weight has to fall off.'"

She realized she needed professional help, and Smith found a therapist who specialized in eating disorders and began treatment at The Renfrew Center, a residential facility in Pennsylvania. She continues to struggle with discussing her weight at medical appointments. After she told her endocrinologist about her treatment at Renfrew, his reply was "I see you need to lose some weight."

Sunday, November 5, 2017

"Research your symptoms," says Eve Muller, a Los Angeles-based actress who has been working in medical schools as a simulated patient since 1990. Bodies manifest ailments in recognizable patterns that medical professionals are trained to observe and diagnose. It is not enough to say your belly hurts; exactly where and how does it hurt? Stomach pain could be food poisoning, an ectopic pregnancy, pelvic inflammatory disease, appendicitis, twisted ovarian tubes or something else entirely. Know your malady's pathology and describe it with specificity. "You need to know anatomy," Muller says.

Before she interacts with students, a medical school gives Muller a detailed case study outlining the pretend patient's medical history, biography, symptoms and sometimes even scripted lines. Be similarly thorough in your preparation. If the condition requires a repeated physical action, like a limp or the trembling associated with Parkinson's disease, watch videos of real patients online and mimic their behavior in front of a mirror or on video. Use makeup, hair and clothing to help tell your story. "Look the part," says Muller, who paints bruises and rashes onto her body. She drinks yogurt smoothies to sound phlegmy if she's portraying someone with congestion. Sometimes she wears business attire; for other characters she jams dirt under her fingernails and rubs oil in her hair.

Sunday, October 29, 2017

Geraldine was warmly opinionated and, along with her husband, she'd raised her four daughters to be the same.

When work settled and time allowed, she melted into the couch next to any of her children who were home and turned on the Hallmark channel. If a movie showed people who couldn't care for themselves, she would remark, "I don't want to live like that," or "if that's me, don't bother doing all that."

On May 25, a clot blocked a blood vessel in Geraldine's heart. Her husband performed CPR. She was whisked to the hospital, where her heart survived, but lack of oxygen launched her brain into uncontrollable seizures. At age 56, her melodic Irish accent was silenced.

Her lips sagged around a breathing tube when I met her three weeks later. Her limbs lay wherever we put them. Kinked gray hair stood in all directions from her scalp, pushed aside by electrodes that recorded brain activity.

In the small conference room in our neuro intensive care unit, we discussed Geraldine's prognosis with her family.

If you've ever put in an eyedrop, some of it has almost certainly spilled onto your eyelid or cheek.

The good news is the mess doesn't necessarily mean you missed. The bad news is that medicine you wiped off your face is wasted by design — and it's well-known to the drug companies that make the drops.

Eyedrops overflow our eyes because drug companies make the typical drop — from pricey glaucoma drugs to a cheap bottle of Visine — larger than a human eye can hold. Some are so large that if they were pills, every time you swallowed one, you'd toss another in the garbage.

The waste frustrates glaucoma experts like Dr. Alan Robin, whose patients struggle to make pricey bottles of drops last. He has urged drug companies to move to smaller drops — to no avail.

"They had no interest in people, their pocketbooks or what the cost of drugs meant," said Robin, a Baltimore ophthalmologist, researcher and adjunct professor at the University of Michigan Medical School.

ProPublica has been documenting the many ways health care dollars are being wasted. We've shown how hospitals throw out brand new supplies, nursing homes flush tons of unexpired medication and drug companies concoct costly combinations of cheap medication. Recently we described how arbitrary drug expiration dates cause us to toss safe and potent medicine.

Wednesday, October 25, 2017

Every medical case, to paraphrase the writer Viet Thanh Nguyen, is lived twice: once in the wards and once in memory. Some of what follows is still intensely vivid, as if it were shot in high-def video. Other parts are blurry — in part because I must have subconsciously deleted or altered the memories. I was 33 then and a senior resident at a hospital in Boston. I had been assigned to the Cardiac Care Unit, a quasi I.C.U. where some of the most acutely ill patients were hospitalized.

In mid-September — it had been a moody, rain-drenched month, as I recall — I admitted a 52-year-old man to the unit. I'll call him by the first letter of his given name, M. As medical interns, we were forewarned by the senior residents not to identify too closely with patients. "A weeping doctor is a useless doctor," a senior once told me. Or: "You cannot do an eye exam if your own eyes are clouded." But M.'s case made it particularly hard. He was a doctor and a scientist — an M.D., a Ph.D., like me. He must have been about 15 years ahead of me in his schooling; I could imagine him returning to my class in med school to teach us "Patient-Doctor," in which students are taught how to deal with real-life patients. He'd trained as a medical resident and then as a fellow in cardiology at another hospital across town. He was now an assistant professor — it seemed like such a victory to have that title — and ran a small laboratory. I knew a student who once worked with him. Six degrees of separation? There was barely one.

Thursday, October 19, 2017

At first, it felt like something was in her eye. Then her eyes turned red, watery and irritated. Her vision became blurry, and she found it difficult to read. It was painful to fly, and to be in air conditioning. Ilene Gipson, a scientist who studies eye disorders, didn't need a specialist to tell her what she had. "I knew what it was," she says.

Gipson had dry eye disease, an ailment that occurs when the eye does not produce enough tears, or when the tears evaporate too quickly. It is the most common eye problem that older women experience, and it disproportionately affects women: more than 3 million women vs. about 1.7 million men, according to the American Academy of Ophthalmology.

And it's not the only one. Many eye disorders — some of them quite serious — seem to favor women over men.

"Women make up two-thirds of the people who are visually impaired or blind in the world," says Janine Clayton, an ophthalmologist who heads the office of research on women's health at the National Institutes of Health. "Most people would say, 'That can't be the case in the United States.' But it is. Unfortunately, we don't know why."

Monday, October 16, 2017

On September 28, 2016, a 3-year-old girl named Elodie Fowler slid into an MRI machine at Lucile Packard Children's Hospital in Palo Alto, California. Doctors wanted to better understand a rare genetic condition that was causing swelling along the right side of her body and problems processing regular food.

The scan took about 30 minutes. The hospital's doctors used the results to start Elodie on an experimental new drug regimen.

Fowler's parents knew the scan might cost them a few thousand dollars, based on their research into typical pediatric MRI scans. Even though they had one of the most generous Obamacare exchange plans available in California, they decided to go out of network to a clinic that specialized in their daughter's rare genetic condition. That meant their plan would cover half of a "fair price" MRI.

They were shocked a few months later when a bill arrived with a startling price tag: $25,000. The bill included $4,016 for the anesthesia, $2,703 for a recovery room, and $16,632 for the scan itself plus doctor fees. The insurance picked up only $1,547.23, leaving the family responsible for the difference: $23,795.47.

Sunday, October 15, 2017

My sister Camilla and I stepped off the passenger ferry onto the dock at Vineyard Haven, Martha's Vineyard's main port, with a group that had already begun their party. They giggled, dragging coolers and beach chairs behind them. We competed to see how many items of Nantucket red we could spot.

Not that we were wearing any. Camilla wore shorts with white long underwear underneath, and I wore beige quick-dry hiking pants. Both of us had on sneakers with long white socks. It was late June, perfect beach weather. The water sparkled. But we weren't headed toward the ocean. We were there to hunt for ticks.

On the island, we hopped in a cab. Camilla looked longingly out the window as we passed the turns for the town beach and Owens Park Beach. The driver pointed out the location of the famous shark attack beach from Jaws. We drove on south to Manuel Correllus State Forest, an unremarkable park in the center of the island and the farthest point from any beach.

Deer ticks, or blacklegged ticks, are poppy-seed sized carriers of Lyme disease. We needed to collect 300 before the last ferry returned to Woods Hole, Massachusetts that night. We each unfurled a drag cloth—a one-meter square section of once-white corduroy attached to a rope—and began to walk, dragging the cloth slowly behind us as if we were taking it for a stroll. The corduroy patch would rise and fall over the leaves and logs in the landscape, moving like a mouse or a chipmunk scurrying through the leaf litter. Ticks, looking for blood, would attach to the cloth. Every 20 meters, we'd stoop to harvest them.

Tick collecting made it to Popular Science's 2004 list of worst science jobs alongside landfill monitor and anal wart researcher. On cool days, though, sweeping the forest floor, kneeling to pluck ticks from corduroy ridges, the job became rhythmic. I felt strangely close to the forest. As I soon found out, the work got me closer to people, too.

Saturday, October 14, 2017

Carmen Walker didn't realize how bad things had gotten until she heard her doctor's voice from across the operating room: "I'm going to try to save her uterus."

Walker had delivered her first child by caesarean section, so when she became pregnant a second time, doctors didn't think twice before scheduling another. And then another and another. Now, giving birth to her sixth child, she was experiencing the consequences: placenta accreta, a condition which is linked to multiple C-sections and can result in fatal bleeding.

Caesarean sections have saved the lives of millions of infants who might have otherwise been killed or permanently injured during difficult births. But in the US, the rate of caesareans has increased so much over the decades that the surgery has been transformed from a life-saving intervention into a procedure performed as a matter of course during one in three US births.

In 2015, the latest year for which the Centers for Disease Control has data, the share of births by C-section was 32%. The World Health Organization has suggested that the rate should not be higher than 10% - 15%, while other experts have suggested it should not be higher than 19%. The last time the US's rate was that low was during the 1970s.

Friday, October 13, 2017

I always liked my primary care doctor personally. He routinely welcomed me to his office with a cheery hello and a smile. We asked about each other's children. We often discussed our respective exercise regimens, running in his case and pickup basketball in mine. For more than 20 years, we even confided about our ambitions as writers.

But I often questioned his judgment in medical matters.

Take, for example, the time my neck bothered me. I complained to him about frequent soreness and stiffness – probably a result of spending hours planted in front of a computer. He suggested I obtain a neck brace to wear while working. "Is that necessary?" I asked him. No, he said.

At no point did he ask me where my neck hurt, or how much, or how often. He never physically examined my neck, nor instructed me to turn my head in order to observe my range of motion. He neglected to propose I do specific exercises to rehabilitate my neck or get a new chair or just take frequent breaks from sitting at a keyboard.

Rather, he advised me to see an orthopedist or physiatrist. He also printed out some medical journal articles about neck problems for me to read, all well over my head.

Some time later, my annual physical revealed my overall cholesterol level to be borderline high. "I should probably put you on a statin," my doctor said. "I could prescribe Lipitor." "Would that be necessary?" I asked him. No, he said.

"It's a trend that reflects the state of medicine today," Dr. Danielle Ofri, associate professor of medicine at NYU Langone Medical Center and author of "What Patients Say, What Doctors Hear," told me. "Physicians are so risk-averse they prescribe medications as a default and reflexively refer patients to specialists. It's systemic."

What to do? After all, this was my health here. As a lifelong recreational athlete and fitness enthusiast, I'd entered my 60s healthy, but eventually – inevitably – my age would catch up with me. Was I going to risk my longevity to avoid hurting my doctor's feelings? I needed a physician I respected and trusted. Should I stick with the status quo or take a hike?

Saturday, October 7, 2017

By the time Nev Jones entered DePaul University's esteemed doctoral program in philosophy, she had aced virtually every course she ever took, studied five languages and become proficient in three, and seemed to have read and memorized pretty much everything. Small and slightly built, with a commanding presence that emerged when she talked, she was the sort of student that sharp teachers quickly notice and long remember: intellectually voracious, relentlessly curious, endlessly capable, and, as one of her high school teachers put it, "magnificently intense." Her mind drew on a well-stocked, seemingly flawless memory with a probing, synthesizing intelligence. With astounding frequency she produced what one doctoral classmate called "genius-level reflections."

So Jones grew alarmed when, soon after starting at DePaul in the fall of 2007, at age 27, she began having trouble retaining things she had just read. She also struggled to memorize the new characters she was learning in her advanced Chinese class. She had experienced milder versions of these cognitive and memory blips a couple times before, most recently as she'd finished her undergraduate studies earlier that year. These new mental glitches were worse. She would study and draw the new logograms one night, then come up short when she tried to draw them again the next morning.

These failures felt vaguely neurological. As if her synapses had clogged. She initially blamed them on the sleepless, near-manic excitement of finally being where she wanted to be. She had wished for exactly this, serious philosophy and nothing but, for half her life. Now her mind seemed to be failing. Words started to look strange. She began experiencing "inarticulable atmospheric changes," as she put it—not hallucinations, really, but alterations of temporality, spatiality, depth perception, kinesthetics. Shimmerings in reality's fabric. Sidewalks would feel soft and porous. Audio and visual input would fall out of sync, creating a lag between the movement of a speaker's lips and the words' arrival at Jones' ears. Something was off.

When I was 15, a teacher I was very close with killed himself over winter break. I found out about it in an AOL chatroom the night before school resumed. My friends were talking about how the elementary school science teacher had died. "The one from when we were kids?" I typed into the chatroom, sitting on the couch between my parents, as the Jennifer Garner show Alias played on our television. "Shit," one of my classmates typed. "We weren't supposed to tell her," another wrote.

John Wake was my little brothers' science teacher, and my after-school photography teacher. I leapt from the couch and called my homeroom teacher at his home. In a quiet, heavy voice, he confirmed what my friends had let slip. I screamed. My parents hovered around me, trying to understand what was happening. Eventually one of them took the phone. I was sobbing, incoherent, and couldn't breathe. I needed air. I ran to the elevator and my father followed me. He walked me down and back up our Manhattan block in pouring January rain, his arm tight around me as I sobbed, tucked into his armpit. The next day in school I was crying at my locker and the guidance counselor walked by. He stopped and turned around after passing me, and asked if I was okay. I looked at him and said with all the raw teenage emotion in my body, "No. My favorite teacher killed himself." The guidance counselor looked back at me, said he hoped I'd feel better, and walked away.

My own mental illness had made itself known a few years earlier. Mr. Wake and I had a special bond, maybe because something in each of us recognized itself in the other person. I had always been a Good Kid — didn't smoke, didn't drink, had never kissed a boy. But when Mr. Wake died, I became angry at the adults in my school. I needed them to talk about this monster that lived inside some of us, sometimes quiet for years at a time, occasionally rousing to try to kill us. When they wouldn't, I punished them the only way my teenage self knew how: I became Bad. I smoked cigarettes in school, cut class to get stoned, threw tantrums at teachers and stormed out, showed up drunk to a school dance with the valedictorian. The adults in charge ignored my acting out, for the most part. I transferred to a new school at the end of the year, in large part because the adults who interviewed me there didn't look away when I confronted them with my sad, ugly, unwieldy pain.

I try now, as an adult, to be sympathetic to those adults at my old school, who shied away from the conversation I so badly wanted to have. They were probably ill-equipped for it. They were probably dealing with their own pain. They probably worried that I wanted answers they didn't have, that simply didn't exist.

In 2003, The Washington Post columnist Marjorie Williams, struggling with liver cancer, wrote that she had finally figured out what bothered her so much about then-presidential candidate Howard Dean: His doctorly arrogance. "Where else but in medicine," she asked, "do you find men and women who never admit a mistake?"

Actually, this happens quite frequently in politics too. But point taken.

Henry Marsh is in the business of admitting his mistakes. It's right there in the title of his second memoir — "Admissions: Life as a Brain Surgeon" — and it was the central theme of his first, "Do No Harm," published in his native England to wide acclaim, in 2014, and then here a year later.

One of the reasons patients find condescension from doctors especially loathsome is that it diminishes them — if you're gravely ill, the last thing you need is further diminishment. But the desires of patients, Marsh notes, are often paradoxical. They also pine for supreme confidence in their physicians, surgeons especially, because they've left their futures — the very possibility of one at all, in some cases — in their doctors' custody. "So we quickly learn to deceive," Marsh writes, "to pretend to a greater level of competence and knowledge than we know to be the case, and try to shield our patients a little from the frightening reality they often face."

Tuesday, September 26, 2017

About 64,000 Americans died from drug overdoses last year—a staggering 21 percent increase from the 52,404 in 2015—according to the first government estimate of drug deaths in 2016. Overdoses now kill more Americans than HIV did at its peak in 1995, and far more than guns or cars do today.

The numbers, released by the Centers for Disease Control and Prevention, are provisional and will be updated monthly, according to the agency.

Fueling the rise in deaths is fentanyl, a synthetic opioid up to 100 times more potent than morphine, and fentanyl analogs, or slight tweaks on the fentanyl molecule. This has not always been the case: As the chart below shows, the drivers of the opioid crisis have changed from prescription painkillers to heroin, and then to fentanyl.

As Dan Ciccarone, a professor at the University of California-San Francisco School of Medicine, recently wrote in the International Journal of Drug Policy:

This is a triple epidemic with rising waves of deaths due to separate types of opioids each building on top of the prior wave. The first wave of prescription opioid mortality began in the 1990s. The second wave, due to heroin, began around 2010 with heroin-related overdose deaths tripling since then. Now synthetic opioid-related overdoses, including those due to illicitly manufactured fentanyl and fentanyl analogues, are causing the third wave with these overdose deaths doubling between 2013 and 2014 .

The epidemic is straining the capacity of morgues, emergency services, hospitals, and foster care systems. Largely because of prevalent drug use and overdose, the number of children in foster care nationwide increased by 30,000 between 2012 and 2015.

I can see him in his glass-fronted Cambridge office from the foosball table in the light-filled central atrium. He's standing there talking to a visitor and seems to be finishing up. This entire side of the third floor in MIT's new Media Labbuilding is partitioned with glass, and professor Hugh Herr and his colleagues and whatever madness they're up to in their offices and the open, gadget-filled, lower-floor lab are on display. Several people, myself included, are peering down, hoping to see a bit of magic.

Months ago, when I e-mailed Herr to propose writing an article about him, I told him about my rare bone cancer and resulting partial paralysis below the waist as a way to explain my interest in his work. Though I didn't tell him this, I also harbored a secret wish that he could help me. People write to Herr, a 52-year-old engineer and biophysicist, daily about his inspiring example. They've heard him promise an end to disability. They have conditions that medicine can't fix and futures they can't stand to consider. They're wishing for his intervention, wanting of hope. Crossing his threshold, I'm the lucky one. I'm here.

Herr welcomes me into his office, a clean, well-ordered space. There's a round glass table with a laptop on it, a handful of hard office chairs, and a pair of prosthetic legs Herr designed that are arranged like statuary behind us, one in either corner. Above us on a wall looms a large mounted photograph of another pair of prosthetics. These are hand-carved from solid ash, with vines and flowers and six-inch heels. The real-life legs were famously worn by a friend of Herr's, the amputee track-and-field athlete and actress Aimee Mullins.

I have hobbled into Herr's office with a dented $20 stock metal cane on one side and a foot-lifting Blue Rocker brace on the other. (The dent is from my recently firing the cane at the wall.) I had imagined Herr noticing the cane and asking more about my story to see how he could fix me, like he has fixed so many others. The moment I realize that the meeting I'd imagined isn't the meeting we're going to have—I'm here as a reporter, not a friend or patient, after all—I start to stammer. Herr deftly resets the conversation by suggesting we look at his computer.

On it are the PowerPoint slides of his next big project, a breathtaking $100 million, five-year proposal focused on paralysis, depression, amputation, epilepsy, and Parkinson's disease. Herr is still trying to raise the money, and the work will be funneled through his new brainchild, MIT's Center for Extreme Bionics, a team of faculty and researchers assembled in 2014 that he codirects. After exploring various interventions for each condition, Herr and his colleagues will apply to the FDA to conduct human trials. One to-be-explored intervention in the brain might, with the right molecular knobs turned, augment empathy. "If we increase human empathy by 30 percent, would we still have war?" Herr asks. "We may not."

As he continues with the presentation he's been giving to technologists, engineers, health researchers, and potential donors—last December alone, he keynoted in Dubai, Istanbul, and Las Vegas—each revolutionary intervention he mentions yields a boyish grin and a look that affirms: Yes, you heard that right. In a talk I hear him give a few weeks ­later, he'll dare to characterize incurable paralysis as "low-hanging fruit." In his outspoken willingness to fix everything, even things that some argue should be left alone, he knows how he sounds. "If half the audience is frightened and the other half is intrigued, I know I've done a good job," he says.

When Alexander Fleming came back from a Scottish vacation in the summer of 1928 to find his London lab bench contaminated with a mold called Penicillium notatum, he kicked off a new age of scientific sovereignty over nature. Since then, the antibiotics he discovered and the many more he inspired have saved millions of lives and spared immeasurable suffering around the globe. But from the moment it started, scientists knew the age of antibiotics came stamped with an expiration date. They just didn't know when it was.

Bacterial resistance to antibiotics is both natural and inevitable. By the luck of the draw, a few bacteria will have genes that protect them from drugs, and they'll pass those genes around—not just to their progeny, but sometimes to their neighbors too. Now, computational epidemiologists are finally getting the data and processing to model that phenomenon. But no one's using these tools to predict the end of the antibiotic era—because it's already here. Instead, they're focusing their efforts on understanding how soon resistant bacteria could be in the majority, and what, if anything, doctors can do to stop them.

In 2013, then-director of the Centers for Disease Control and Prevention Tom Frieden told reporters, "If we're not careful, we will soon be in a post-antibiotic era." Today, just four years later, the agency says we've arrived. "We say that because pan-resistant bacteria are now here" says Jean Patel, who leads the CDC's Antibiotic Strategy & Coordination Unit. "Folks are dying simply because there is no antibiotic available to treat their infection, infections that not too long ago were easily treatable."

Last August, a woman in her 70s checked into a hospital in Reno, Nevada with a bacterial infection in her hip. The bug belonged to a class of particularly tenacious microbes known as carpabenem-resistant Enterobacteriaceae, or CREs. Except in addition to carpabenem, this bug was also resistant to tetracycline, and colistin, and every single other antimicrobial on the market, all 26 of them. A few weeks later she developed septic shock and died.

For public health officials like Patel, that case marks the end of an era, and the beginning of a new one. Now, the question is: How fast is that kind of pan-resistance going to spread? "When does it get to the point where it's more common to have an infection that can't be treated with antibiotics than one that can?" says Patel. "That's going to be a very hard thing to predict."

ABOARD THE GOLFO AZZURRO—An urgent plea woke the ship's doctor, John Vallentine, at 6:30 a.m. He was needed on the bridge.

The rescue ship was steaming south in the Mediterranean Sea in a race to reach a deflating rubber dinghy packed with migrants. Italy's coast guard had transmitted the coordinates, along with a warning the makeshift craft could soon sink.

A voice crackling across the radio told of another emergency. A lone West African man plucked from the sea by a nearby vessel was grievously ill with a soaring fever and convulsions. "He is unconscious and not responding," the radio voice said.

Dr. Vallentine and the crew of the Golfo Azzurro had a decision to make. They could help the stricken man, which would delay their mission to find the dinghy. Crew members knew from experience what happens when inflatable crafts fail. Seawater and fuel pool in the middle, weighing boats down into the sea. The liquids form a corrosive mixture that eats away at the flesh of those stuck in the crowded boat. Panic erupts and people drown.

The other option would be to continue on their course. They didn't know the dinghy's exact condition or whether another ship could rescue it. And without immediate medical care, the man on the boat a half-hour west would almost certainly die.

As a professor of medical ethics back home in Australia, Dr. Vallentine delighted in challenging students with the kinds of complex moral questions that can make the practice of medicine uncomfortable. Those often centered on issues of privacy and social responsibility, such as whether doctors should warn police about a mentally ill patient who owns guns.

In the chaos of a humanitarian disaster, such as when thousands of African and Middle Eastern migrants try to cross the Mediterranean in flimsy vessels, there are few rules about whom to help and in what order.

"It's all about finite resources in a world of infinite need," said Dr. Vallentine, who is 70 years old. "Do I look after this one, that 10, this 600?"

Some philosophers and ethicists say the overriding consideration should be to preserve as many lives as possible, even if it requires sacrificing individuals along the way. Others argue that all lives are equally worth saving and it is wrong to deny help to those who need it.

In practice, doctors use all kinds of methods to prioritize care in the pandemonium of a catastrophe. The notion of triage was a creation of battlefield medicine during the Crimean War. Some doctors handle the gravest cases first, others favor children over adults, and others stick to a first-come, first-served system, finding it hard to give up on a suffering patient to help others they haven't yet seen.

The decision in front of him reminded Dr. Vallentine of an exam question from his medical training. If he was treating a casualty in a war zone and the area suddenly became dangerous, would he leave, saving himself and letting his patient die so that he could treat more people on another day?

He recalled his answer: "I said I would leave." That suggested that the Golfo Azzurro should go look for the dinghy.

Saturday, September 23, 2017

It's a little after sunrise on the first day of another week, and Cincinnati is waking up again with a heroin problem. So is Covington. And Middletown. And Norwood. And Hamilton. And West Chester Township. And countless other cities and towns across Ohio and Kentucky.

This particular week, July 10 through 16, will turn out to be unexceptional by the dreary standards of what has become the region's greatest health crisis.

This is normal now, a week like any other. But a terrible week is no less terrible because it is typical. When heroin and synthetic opiates kill one American every 16 minutes, there is little comfort in the routine.

There is only the struggle to endure and survive.

MONDAY

"I just walked in and my buddy, he hasn't been answering his phone. I believe he's OD'd and I think he's dead."

7:25 A.M.

Jimmy Doherty arrives at the halfway house on Ravine Street still wearing the blue slippers he got in jail.

He came straight here after his release this morning because he thinks the program at the Pax House in Cincinnati will help him get his addiction under control.

"We'll get you going," says the house manager.

Doherty crushes his cigarette and sits down to fill out a form for new residents, but he's stumped by a question about his history with drugs. It's a long history.

"Describe all mood-altering substances?" Doherty asks.

The manager shakes his head. "Drug of choice," he says. "Just put your drug of choice."

Doherty nods. He turns back to the page and writes a single word.

Heroin.

9 A.M.

On some days, even before she calls their names, Judge Gwen Bender can tell why the defendants are in Courtroom A.

Their bones look as if they might poke through their skin. Their eyes are sunken, their hair a tangled mess. Some are unsteady on their feet. Others scratch at sores on their arms.

A few lean on the table in front of the judge as if it is the only thing holding them up.

"This is a heroin case?" the judge asks.

This morning, as on most mornings, one in four felony cases on this Hamilton County court docket is directly connected to heroin.

There's a 70-year-old Army veteran who stashed a bag of syringes in a basement crawl space. A Taylor Mill woman who tried to hide needles in her vagina after shooting up. A St. Bernard woman who overdosed when a friend injected her with heroin.

The woman from St. Bernard looks confused, as if she's unsure how she got here. She was on the floor of her friend's house, barely breathing, less than 12 hours ago.

In September, 2016, Donald Trump delivered a speech at the Economic Club of New York. "Today, I'm going to outline a plan for American economic revival," he said. "It is a bold, ambitious, forward-looking plan to massively increase jobs, wages, incomes, and opportunities for the people of our country." He went on to talk about lowering taxes and removing regulations, renegotiating trade deals and building a border wall. But he overlooked one of the most pressing issues facing the American economy today: the opioid crisis.

Politicians tend to talk about the crisis in moral terms, focussing on the ways in which opioid addiction has ravaged families and communities. The New Jersey governor, Chris Christie, whom Trump appointed to lead a commission to study the issue, has compared opioid-overdose fatalities to terrorist attacks, saying, "We have a 9/11-scale loss every three weeks." Opioids, which include prescription painkillers and drugs like heroin and fentanyl, are indeed responsible for large-scale human suffering. According to the National Survey of Drug Use and Health, 97.5 million Americans used, or misused, prescription pain pills in 2015. Drug-overdose deaths have tripled since 2000, and opioid abuse now kills more than a hundred Americans a day. But often omitted from the conversation about the epidemic is the fact that it is also inflicting harm on the American economy, and on a scale not seen in any previous drug crisis.

In July, when economists at Goldman Sachs analyzed how the 2008 financial crisis and its aftermath may have contributed to levels of opioid addiction, they noted that fewer prime working-age men are participating in the labor force than in the past, and that many of these men have been found to be taking prescription pain medication. Research by the Princeton economist Alan Krueger, published last week, indicates a definitive link between the two.

Other studies have tried to put an exact figure on the cost of the epidemic. A study published in the journal Pain Medicine in 2011 estimated that health-care costs related to prescription opioid abuse amounted to twenty-five billion dollars, and criminal-justice-system costs to $5.1 billion. But the largest cost was to the workplace, which accounted for $25.6 billion, in the form of lost earnings and employment. "There are major consequences to the economy, not just to the employer and employee who are losing productivity but also to civil society," Howard Birnbaum, a health-care economist with the Analysis Group and one of the authors of the study, told me recently. "If people don't have jobs, they don't have money to spend in the grocery store, on gasoline. It's the old multiplier effect: the socioeconomic burden is much broader than on any individual or any firm." The study estimated a total cost to the economy of $55.7 billion, but, Birnbaum said, "I suspect it is even larger now."Another study, just two years later, reached a total of $78.5 billion.

When I spoke with Anupam Jena, a health economist and physician at Harvard Medical School, he argued that such figures don't include the most dramatic cost: the economic value of the loss of life. Taking a conservative estimate of twenty to thirty thousand opioid-related deaths a year and multiplying those numbers by five million dollars—a figure commonly used by insurance companies to value a human life—Jena estimated that loss of life alone costs the economy an additional sum of between a hundred and a hundred and fifty billion dollars a year. All these figures suggest that addiction prevention and treatment should be a part of any serious policy discussion about how to strengthen the U.S. economy.

The trail of painkillers leads to West Virginia's southern coalfields, to places like Kermit, population 392. There, out-of-state drug companies shipped nearly 9 million highly addictive — and potentially lethal — hydrocodone pills over two years to a single pharmacy in the Mingo County town.

Rural and poor, Mingo County has the fourth-highest prescription opioid death rate of any county in the United States.

The trail also weaves through Wyoming County, where shipments of OxyContin have doubled, and the county's overdose death rate leads the nation. One mom-and-pop pharmacy in Oceana received 600 times as many oxycodone pills as the Rite Aid drugstore just eight blocks away.

In six years, drug wholesalers showered the state with 780 million hydrocodone and oxycodone pills, while 1,728 West Virginians fatally overdosed on those two painkillers, a Sunday Gazette-Mail investigation found.

Thursday, September 21, 2017

When Penny Mae Cormani died in Utah, her family sang Mormon hymns — "Be Still My Soul" — and lowered her small coffin into the earth. The latest victim of a drug epidemic that is now taking 60,000 lives a year, Penny was just 1.

Increasingly, parents and the police are encountering toddlers and young children unconscious or dead after consuming an adult's opioids.

At the children's hospital in Dayton, Ohio, accidental ingestions have more than doubled, to some 200 intoxications a year, with tiny bodies found laced by drugs like fentanyl. In Milwaukee, eight children have died of opioid poisoning since late 2015, all from legal substances like methadone and oxycodone. In Salt Lake City, one emergency doctor recently revived four overdosing toddlers in a night, a phenomenon she called both new and alarming.

"It's a cancer," said Mauria Leydsman, Penny's grandmother, of the nation's opioid problem, "with tendrils that are going everywhere."

While these deaths represent a small fraction of the epidemic's toll, they are an indication of how deeply the American addiction crisis has cut.

Tuesday, September 5, 2017

Drug overdoses killed roughly 64,000 people in the United States last year, according to the first governmental account of nationwide drug deaths to cover all of 2016. It's a staggering rise of more than 22 percent over the 52,404 drug deaths recorded the previous year — and even higher than The New York Times's estimatein June, which was based on earlier preliminary data.

Drug overdoses are expected to remain the leading cause of death for Americans under 50, as synthetic opioids — primarily fentanyl and its analogues — continue to push the death count higher. Drug deaths involving fentanyl more than doubled from 2015 to 2016, accompanied by an upturn in deaths involving cocaine and methamphetamine. Together they add up to an epidemic of drug overdoses that is killing people at a faster rate than the H.I.V. epidemic at its peak.

A study published in July in the journal Neurobiology of Aging found that artificial intelligence could detect signs of the disease in patient brain scans before physicians. The computer-based algorithm was able to correctly predict if a person would develop Alzheimer's disease up to two years before he or she actually displayed symptoms. It was correct 84 percent of the time.

Researchers are hopeful that the tool will be helpful in determining before the onset of the disease which patients to choose for clinical trials or for drugs that could slow its progression and delay its crippling effects.

"If you can tell from a group of individuals who is the one that will develop the disease, one can better test new medications that could be capable of preventing the disease," co-lead study author Dr. Pedro Rosa-Neto, an associate professor of neurology, neurosurgery and psychiatry at McGill University, told Live Science.

The researchers were able to train the artificial intelligence program to recognize Alzheimer's disease in the brain by showing it before and after scans of 200 people who had the disease. The AI technology was then shown scans of 270 volunteers – 43 of whom eventually developed Alzheimer's. The AI technology was able to accurately predict 84 percent of the cases in which the volunteers eventually developed the disease.

Monday, September 4, 2017

Last month, a White House panel declared the nation's epidemic of opioid abuse and deaths "a national public health emergency," a designation usually assigned to natural disasters.

A disaster is indeed what it is, with 142 Americans dying daily from drug overdoses, a fourfold increase since 1999, more than the number of people killed by gun homicides and vehicular crashes combined. A 2015 National Survey on Drug Use and Health estimated that 3.8 million Americans use opioids for nonmedical reasons every month.

Lest you think that people seeking chemically induced highs are solely responsible for the problem, physicians and dentists who prescribe opioids with relative abandon, and patients and pharmacists who fill those prescriptions, lend a big helping hand. The number of prescriptions for opioids jumped from 76 million in 1991 to 219 million two decades later. They are commonly handed to patients following all manner of surgery, whether they need them or not.

A new review of six studies by Dr. Mark C. Bicket and colleagues at Johns Hopkins University School of Medicine found that among 810 patients who underwent seven different kinds of operations, 42 percent to 71 percent failed to use the opioids they received, and 67 percent to 92 percent still had the unused drugs at home.

Wednesday, August 30, 2017

The Food and Drug Administration on Wednesday approved a futuristic new approach to treating cancer, clearing a Novartis therapy that has produced unprecedented results in patients with a rare and deadly cancer. The price tag: $475,000 for a course of treatment.

That sounds staggering to many patients — but it's far less than analysts expected.

The therapy, called a CAR-T, is made by harvesting patients' white blood cells and rewiring them to home in on tumors. Novartis's product is the first CAR-T therapy to come before the FDA, leading a pack of novel treatments that promise to change the standard of care for certain aggressive blood cancers.

Novartis's therapy is approved to treat children and young adults with relapsed acute lymphoblastic leukemia. It will be marketed as Kymriah.

The treatment's approval has looked a foregone conclusion for months, but its potential price has been the subject of speculation and debate. Novartis picked the $475,000 price tag in an effort to balance patient access to Kymriah while giving the company a return on its investment, said Bruno Strigini, Novartis's head of oncology, in a conference call Wednesday. The cost is below Wall Street analyst expectations, which reached as high as $750,000 for a dose. And it's considerably cheaper than the roughly $700,000 price tag that U.K. regulators said would be fair considering Kymriah's potential benefits.

Novartis also said it is working with Medicare on a system in which the government would only pay for CAR-T treatment if patients respond within a month.

In a clinical trial, a single dose of Kymriah left 83 percent of participants cancer-free after three months, results oncologists have hailed as a major advance for patients with few other options. The most frequent side effect was an inflammatory storm called cytokine release syndrome, a reaction to CAR-T that can prove fatal in some patients but is commonly controlled with immunosuppressant drugs.

"I think this is most exciting thing I've seen in my lifetime," said Dr. Tim Cripe, an oncologist with Nationwide Children's Hospital, at an FDA meeting on Kymriah in July.

Tooth enamel is the strongest substance in the human body. It's harder than steel. Which helps explain why the three words "root canal treatment" often strike such terror into patients sitting in the dental chair. It starts by boring a hole through enamel as effortlessly as if it were rice paper. Ninety-nine percent of the time, that gaping hole is filled and sealed immediately after treatment. A few months ago, I met a patient I'll call Janet, to protect her privacy. She was one of the 1 percent.

I carefully peered my head into her mouth. The remaining pulp, or core, of the treated tooth—an amalgam of nerves, blood vessels, and immune cells—had blossomed out of the fractured crown into a twisting, intersecting polyp with the color and consistency of bubble gum. She had chronic hyperplastic pulpitis, a rare inflammatory condition that triggers pulp tissue to irreversibly expand above the walls of the enamel shell. I pulled my stethoscope off the shelf and checked what I had been trained to with every new patient: her blood pressure. 174 over 104, I whispered to myself, having expected only a slight deviation from the normal 120 over 80. This seemed impossible. I checked the other arm; 172/104. I waited 15 minutes and checked again. 164/100.

Hypertensive emergency, which can cause patients to spontaneously suffer a severe stroke, heart attack, or kidney damage, occurs when blood pressure reaches 180/110 or higher. While her blood pressure was trending downward, Janet was dangerously close to that threshold. I asked her if any physician in the past had ever told her that she had high blood pressure. A recent Dominican immigrant unsure of her past medical history, she told me she couldn't remember. Her expanding pulp, a rarity for me, was only a distraction from a bigger concern—her heart. I immediately called her primary care physician, discussed the situation, and told her to go see her doctor immediately. Janet, who had showed up for some basic dental work, had been inches away from a medical emergency.

A 2016 Association of American Medical Colleges report projects that over the next 10 years, the U.S. will face a serious physician shortage, especially among primary care physicians in rural geographic areas. Despite increased health insurance coverage for millions of Americans over the last few years, affordable health care is still difficult to access in rural areas. Certain states, such as Tennessee, Iowa, and my home state of Arizona, are seeing insurance companies drop out of individual markets due to political uncertainty, making access to affordable care harder for a significant fraction of the U.S. population, including many of those I grew up with.

Tuesday, August 29, 2017

Years ago, a palliative care doctor told me that what he knew of a patient's personality often had little to do with how he or she coped with dying. Generous people could become ungenerous, and brave people could become frightened. Angry people could become gentle, and controlling people could become Zen. Dying, in other words — like combat, like becoming a parent, like any transformative life event — doesn't always reveal or intensify aspects of our character. It sometimes coaxes out new ones.

For a long time, the writer Cory Taylor took, by her own admission, "a fairly leisurely approach to life." That changed in 2005, just before her 50th birthday, when doctors removed a mole on the back of her leg. Melanoma, Stage 4. She wrote the novel she'd always meant to write, then another. Then she wrote "Dying: A Memoir."

The book rings louder in my imagination the more time I spend apart from it, a kind of reverse Doppler effect. "Dying" is bracing and beautiful, possessed of an extraordinary intellectual and moral rigor. Every medical student should read it. Every human should read it. My own copy is so aggressively underlined it looks like a composition notebook.

"Dying" is short, but as dense as dark matter. There is an electrifying matter-of-factness to it, one that normalizes death, which is part of Taylor's goal. She deplores the "monstrous silence" surrounding the subject of mortality. "If cancer teaches you one thing," she writes, "it is that we are dying in our droves, all the time. Just go into the oncology department of any major hospital and sit in the packed waiting room."

A Food and Drug Administration panel opened a new era in medicine on Wednesday, unanimously recommending that the agency approve the first-ever treatment that genetically alters a patient's own cells to fight cancer, transforming them into what scientists call "a living drug" that powerfully bolsters the immune system to shut down the disease.

If the F.D.A. accepts the recommendation, which is likely, the treatment will be the first gene therapy ever to reach the market in the United States. Others are expected: Researchers and drug companies have been engaged in intense competition for decades to reach this milestone. Novartis is now poised to be the first. Its treatment is for a type of leukemia, and it is working on similar types of treatments in hundreds of patients for another form of the disease, as well as multiple myeloma and an aggressive brain tumor.

To use the technique, a separate treatment must be created for each patient — their cells removed at an approved medical center, frozen, shipped to a Novartis plant for thawing and processing, frozen again and shipped back to the treatment center.

A single dose of the resulting product has brought long remissions, and possibly cures, to scores of patients in studies who were facing death because every other treatment had failed. The panel recommended approving the treatment for B-cell acute lymphoblastic leukemia that has resisted treatment, or relapsed, in children and young adults aged 3 to 25.

One of those patients, Emily Whitehead, now 12 and the first child ever given the altered cells, was at the meeting of the panel with her parents to advocate for approval of the drug that saved her life. In 2012, as a 6-year-old, she was treated in a study at the Children's Hospital of Philadelphia. Severe side effects — raging fever, crashing blood pressure, lung congestion — nearly killed her. But she emerged cancer free, and has remained so.

"We believe that when this treatment is approved it will save thousands of children's lives around the world," Emily's father, Tom Whitehead, told the panel. "I hope that someday all of you on the advisory committee can tell your families for generations that you were part of the process that ended the use of toxic treatments like chemotherapy and radiation as standard treatment, and turned blood cancers into a treatable disease that even after relapse most people survive."

The main evidence that Novartis presented to the F.D.A. came from a study of 63 patients who received the treatment from April 2015 to August 2016. Fifty-two of them, or 82.5 percent, went into remission — a high rate for such a severe disease. Eleven others died.

"It's a new world, an exciting therapy," said Dr. Gwen Nichols, the chief medical officer of the Leukemia and Lymphoma Society, which paid for some of the research that led to the treatment.

The next step, she said, will be to determine "what we can combine it with and is there a way to use it in the future to treat patients with less disease, so that the immune system is in better shape and really able to fight." She added, "This is the beginning of something big."

"I enjoy working out at the gym," declares one profile. "To keep myself fit, I like to hike, bike and exercise," says another.

These comments aren't part of a dating site. Rather, they come from physicians' online profiles that prospective patients view when they are looking for a new doctor.

There are good reasons doctors might strive to lead by example. "I practice what I preach by living healthy every day," declares one physician on Kaiser Permanente's online doctor search portal. Patients may trust or be inspired by such a doctor, the thinking goes. And if health care professionals fail to follow their own advice, they may be accused of hypocrisy.

But for some patients, particularly those battling weight issues, a doctor's declarations of personal fitness may not have the intended effect of attracting new patients. Instead, rather than inspiring them, it can drive them away.

Recently, my colleague Benoît Monin and I studied doctors who advertise their fitness online. Past research has shown that people worry that those who claim the moral high ground will look down on others whose behavior seems unfavorable by comparison. For example, meat-eaters worry that vegetarians will judge them because of their diet. We wondered: Could emphasizing fitness make doctors seem "healthier than thou" and turn off patients?

We thought that people who are overweight and obese might be particularly sensitive to judgment from doctors. Unlike unhealthy habits such as smoking, weight can't be hidden. Research shows that negative attitudes toward people who are overweight are surprisingly prevalent among health professionals. So potential patients who are overweight might be especially turned off by doctors who show off healthy habits.

To test this idea, in research recently published in the Journal of Personality and Social Psychology, we turned to the real-world examples of physicians practicing what they preach on the website for Kaiser Permanente, the largest managed care organization in the United States. Here, patients choose among dozens of doctors from self-descriptions only a few sentences long, making any information provided consequential. We asked adults who were overweight or obese to rate a sample of these profiles. Some physicians emphasized their fitness in these profiles, while others did not.

In my daily work as a primary care internist, I see no letup from pain. Every single patient, it seems, has an aching shoulder or a bum knee or a painful back. "Our bodies evolved to live about 40 years," I always explain, "and then be finished off by a mammoth or a microbe." Thanks to a century of staggering medical progress, we now live past 80, but evolution hasn't caught up; the cartilage in our joints still wears down in our 40s, and we are more obese and more sedentary than we used to be, which doesn't help.

So it's no surprise that chronic arthritis and back pain are the second and third most common non-acute reasons that people go to the doctor and that pain costs America up to $635 billion annually. The pain remedies developed by the pharmaceutical industry are only modestly effective, and they have side effects that range from nausea and constipation to addiction and death.

What's often overlooked is that the simple conversation between doctor and patient can be as potent an analgesic as many treatments we prescribe.

In 2014, researchers in Canada did an interesting study about the role of communication in the treatment of chronic back pain. Half the patients in the study received mild electrical stimulation from physical therapists, and half received sham stimulation (all the equipment is set up, but the electrical current is never activated). Sham treatment — placebo — worked reasonably well: These patients experienced a 25 percent reduction in their levels of pain. The patients who got the real stimulation did even better, though; their pain levels decreased by 46 percent. So the treatment itself does work.

Each of these groups was further divided in half. One half experienced only limited conversation from the physical therapist. With the other half, the therapists asked open-ended questions and listened attentively to the answers. They expressed empathy about the patients' situation and offered words of encouragement about getting better.

Patients who underwent sham treatment but had therapists who actively communicated reported a 55 percent decrease in their pain. This is a finding that should give all medical professionals pause: Communication alone was more effective than treatment alone. The patients who got electrical stimulation from engaged physical therapists were the clear winners, with a 77 percent reduction in pain.

Just after residency at Bellevue Hospital in New York City, I worked briefly in a private practice in rural Florida. One afternoon, the E.R. called about a man with very high blood pressure — not high enough to be admitted to the hospital, but high enough to need prompt treatment. "Send him over to our office," I said.

When the Mexican farmworker arrived, the office manager hissed at me: "You can't just bring these patients here." Initially I was perplexed; I was preventing an admission to the hospital, saving thousands of dollars. But then I realized — this office would not treat him because he lacked insurance and means.

As the only person in the office who spoke Spanish, I had to break the news. This was the lowest moment in my medical career and I vowed never to have to utter such words to a patient again. I scrambled back to Bellevue and never looked back.

Rachel Pearson repeatedly found herself in the same miserable situation during her medical school training in Galveston, Tex. The island city had been devastated by Hurricane Ike in September 2008, just before Pearson arrived. There's no doubt that the University of Texas Medical Branch (U.T.M.B.) took a financial hit from the natural disaster, but many suspected that the draconian cuts to charity care were already in the works; the hurricane was merely convenient cover.

"It was January when Susan's patients began to die," Pearson writes in her engrossing book, part med-school memoir, part probing moral inquiry. Susan, a cancer surgeon at U.T.M.B., was unable to treat her patients after the medical center — without her knowledge — sent her patients a letter saying the doctor would be "discontinuing her professional relationship" with the people in her care. Without an operating room (and access to chemotherapy and radiation), the surgeon could only visit her patients at home and hold their hands as the disease killed them.

Pearson, who comes from a working-class family herself, finds her element at St. Vincent's House, a social-services center in one of Galveston's poorer neighborhoods, which were disproportionately devastated by Hurricane Ikeand then disproportionately ignored during the rebuilding. At first, she is "under the impression that there was a safety net." With the bare bones of donated supplies, the students diagnose cancer, heart disease and other standard medical fare. But they quickly learn that U.T.M.B. and other hospitals would not be stepping in to deliver medical treatment. A fellow medical student concludes bitterly, "I didn't realize that we were the safety net."

Monday, August 28, 2017

I've failed to complete this post a number of times. It's laden with caveats and nuances and limited to just my learning, but it's important that everyone becomes familiar and adept at how to support the cancer patient. But I think it's applicable to any patient whose life is threatened.

Thanks to science and medicine, many Americans get well into middle age before a friend becomes gravely ill. We know how to talk about in hushed tones amongst ourselves but barring previous misfortune have no idea how to properly respond. But even more importantly I found many adults flounder to respond because they haven't had to grapple with overwhelming senses of despair and helplessness and the secret they dare not verbalize that they and their family are just as vulnerable. The last thing a patient needs is for their friends and acquaintances to respond from a crazed, fearful place. For some it's just too much and they can't even show up. For others it's becomes about them, offering to help just to avoid facing what I describe above. Plenty of others want to help simply because they don't know what to do. Some people figure it out quickly and get with the program. A small few have the life experience to approach it the right way, while some other expert humans are simply so comfortable accepting that life is change and emotions are life that they're naturals.

So, the first part of being good to the patient is to get your own head together. Be mindful of how this is making you feel. Channel your fear of this happening to your family into a celebration of being alive. Accept that feeling helpless isn't a shortcoming. Recognize despair and grief are part of the pantheon of life experiences. You do this because you don't want to make any of this about you. Support and love must flow to the patient and fear and discomfort must flow away. If you are not good at expressing love and gratefulness to your friend, learn how to do so quickly.

Sunday, August 27, 2017

For Jon Lubecky, the scars on his wrists are a reminder of the years he spent in mental purgatory.

He returned from an Army deployment in Iraq a broken man. He heard mortar shells and helicopters where there were none. He couldn't sleep and drank until he passed out. He got every treatment offered by Veterans Affairs for post-traumatic stress disorder. But they didn't stop him from trying to kill himself — five times.

Finally, he signed up for an experimental therapy and was given a little green capsule. The anguish stopped.

Inside that pill was a compound named MDMA, better known by dealers and rave partygoers as ecstasy. That street drug is emerging as the most promising tool to come along in years for the military's escalating PTSD epidemic.

The MDMA program was created by a small group of psychedelic researchers who had toiled for years in the face of ridicule, funding shortages and skepticism. But the results have been so positive that this month the Food and Drug Administration deemed it a "breakthrough therapy" — setting it on a fast track for review and potential approval.

The prospect of a government-sanctioned psychedelic drug has generated both excitement and concern. And it has opened the door to scientists studying new uses for other illegal psychedelics like LSD and psilocybin (commonly known as magic mushrooms).

"We're in this odd situation where one of the most promising therapies also happens to be a Schedule 1 substance banned by the [Drug Enforcement Administration]," said retired Brig. Gen. Loree Sutton, who until 2010 was the highest ranking psychiatrist in the U.S. Army.

Because of the stigma attached to psychedelics since the trippy 1960s, many military and government leaders still hesitate to embrace them. Some scientists are also wary of the nonprofit spearheading ecstasy therapy, a group with the stated goal of making the banned drugs part of mainstream culture.

But the scope and severity of PTSD makes it all irrelevant, said Sutton, who now works as New York City's commissioner of veteran services. "If this is something that could really save lives, we need to run and not walk toward it. We need to follow the data."

A landmark drug study has opened up a potent way to lower the risk of heart attacks — beyond the now standard advice of reducing cholesterol — promising new avenues of treatment of Americans' number one killer.

The findings, more than two decades after the discovery of powerful cholesterol-lowering drugs, called statins, taken by tens of millions, were announced Sunday at a medical conference in Barcelona and published in two leading medical journals.

Physicians not involved in the study described the results as a scientific triumph, calling the implications for drug treatment of heart disease "huge."

The findings provide validation of an idea that has been tantalizing cardiologists for years: that reducing inflammation could be a way to treat artery-clogging heart disease.

"It's a new paradigm: a new opportunity to further reduce death and disability," said Mark Creager, a past president of the American Heart Association, who was not involved in the study. "We've made such tremendous inroads in treating heart disease over the last couple of decades, and it's hard to imagine we could confer additional benefits, but here you go."

But the implications and timing of any benefit for patients remain to be seen. The drug company that sponsored the trial, Novartis, plans to meet with regulators this fall and file for approval by the end of the year. The drug, an injection given once every three months, would then be reviewed by the Food and Drug Administration.

A key question is which patients will benefit; the study showed its effect — a 15 percent drop in a combined measure of heart attacks, stroke and cardiovascular death — in a select, high-risk population of people who had suffered a previous heart attack and had high levels of a marker of inflammation in their blood. But a subset of patients appeared to get greater benefit from the drug, called canakinumab.